Application for a

Medicare Entitlement Statement

Purpose of this form Certified copies of the following:

To apply for an exemption from the Medicare levy in your income tax
return, you must supply a Medicare Entitlement Statement certifying
that you are not eligible for Medicare to the Australian Taxation Office
(ATO).
The Income Tax Assessment Act 1936 makes the Medicare levy
payable by individuals residing in Australia who are eligible for
Medicare. Persons who are not eligible for Medicare can apply for
an exemption from the Medicare levy in their income tax return.
photo page of your passport
evidence of visa(s) to cover the period you are claiming
all Australian arrival stamps, and
if you resided in the United Kingdom, Northern Ireland, Italy,
Malta, Sweden, the Netherlands, Finland, Norway, Belgium or
Slovenia prior to entering Australia, a copy of your European
Health Insurance Card (EHIC), National Health Service (NHS)
card or other health/medical insurance card specific to the
country, showing an expiry date.

Persons not eligible for Medicare
You are not eligible for Medicare if you are a:
permanent resident of Australia, and
have been absent from Australia for 12 months or more.
do not live in Australia.
have not returned to Australia to reside permanently.
are residing in Norfolk Island.
Australian citizen who
has been absent from Australia for more than 5 years.
resides in Norfolk Island.
New Zealand Citizen who travels frequently in and out of
Australia and spends less than 6 months in a 12 month period
in Australia.
person who
was not residing in one of the following countries prior to
entering Australia - the United Kingdom, Northern Ireland,
Italy, Malta, Sweden, the Netherlands, Finland, Norway,
Belgium or Slovenia. These countries have a Reciprocal
Where your visa has been issued electronically and is not
endorsed in your passport, please provide a copy of the letter or
email issued to you by the Department of Immigration and Border
Protection (DIBP). Visa evidence sent to you from DIBP via email
does not need to be certified.
In some cases, we may request that you provide Australian
departure stamps or other certified evidence.
Who can certify documents?
A number of people can certify documents. Examples include:
legal practitioners
medical practitioners
pharmacists
police officers
justice of the peace.
For a complete list of people who can certify documents, go to
ag.gov.au/Publications/Pages/Statutorydeclarationsignatorylist.aspx
www.

Health Care Agreement with Australia.

has not applied for permanent residency. For more information
Even if you are not eligible for Medicare, you may still not be For more information about the Medicare Entitlement Statement, go
eligible for an exemption if you maintain a dependant that is to our website humanservices.gov.au
www.

eligible for Medicare. The ATO make the determination on whether

you are eligible for an exemption.
Filling in this form
Please use black or blue pen
How to apply Print in BLOCK LETTERS
A separate application form is required for each financial year. Mark boxes like this with a or 7
(A financial year runs from 1 July to 30 June.) Where you see a box like this Go to 5 skip to the question
When your application has been assessed and processed, you number shown. You do not need to answer the questions in
will receive a Medicare Entitlement Statement which will certify
between.
that you are not eligible for Medicare benefits for the specified
period.
You should not apply for a Medicare Entitlement Statement for Returning your form
the current financial year unless you are leaving Australia and Check that you have answered all the questions you need to answer
will be submitting a final income tax return before the end of and that you have signed and dated this form.
the financial year.
If a tax agent prepares the application, the tax agent must Send the completed application(s) and certified document(s) for each
complete the tax agent details in this application form. application to:
Fax: 1300 554 904
or
Documents required Department of Human Services
The following documents must be submitted when lodging this form. Medicare Entitlement Statement Unit
Failing to do so will result in a delay in the assessment of your GPO Box 9822
application. ADELAIDE SA 5001

MS015.1410 (formerly 3169) 1 of 3

 Application for a
Medicare Entitlement Statement

1 Is your tax agent completing this application on your behalf? 9 Daytime phone number
No Go to 5 ( )
Yes
Email
2 Do you give permission for your tax agent to supply and receive
information related to this application?
No @
Yes 10 Your residential address in Australia

Tax agents details

Questions 3 and 4 must be completed by the tax agent.
3 Name of company Postcode
Vins Taxation Services
11 This question must be completed if one of the following
Name of person who prepared this application applies:
Sree Kuchi you have left Australia permanently, or
Daytime phone number you are in Australia and your postal address is different
to your residential address, or
( 02 ) 98937877
a tax agent is completing this application.
4 Have you read and understood the Privacy notice contained in What is the postal address you would like all correspondence
this form? sent to?
No PO Box 3918
Yes
Parramatta
Applicants details
NSW Postcode 2124
5 Do you have a Medicare card?
Country (if not Australia)
No
Yes Provide your Medicare Card Number or Reference Correspondence related to this application will be forwarded
number (if known) to this address.
Medicare card number
12 Is the postal address provided in question 11 your tax agents
 Ref no. address?
6 Show your name as it appears on your passport No
Yes
Dr Mr Mrs Miss Ms Other
Family name Eligibility for Medicare
13 What was your country of residence immediately prior to
First given name arriving in Australia?

Second given name

14 How long were you residing in that country? (State total number
of years and/or months in numerals e.g. 10.)

7 Sex Years and/or months

Male 15 Did you hold health or medical insurance in that country (e.g.
Female European Health Insurance Card)?
8 Date of birth No
/ / Yes Provide certified copies of the medical
insurance with this application.
MS015.1410 (formerly 3169) 2 of 3
16 Have you lodged a permanent resident visa application (other Checklist
than a parent visa) with the Department of Immigration and
Border Protection (DIBP)? 25 Which of the following certified copies of documents and other
attachments are you providing with this application?
No Go to 20
Yes Date application lodged Where you are asked to supply documents, please attach
certified copies of original documents.
/ /
Photo page of your passport
17 Have you lodged an application for permanent residency that is Evidence of visa(s) covering the period being
being considered by DIBP and is still current (ongoing)? claimed
No European Health Insurance Card or equivalent
Yes Go to 21 health/medical insurance card or letter, showing
18 Indicate if your application for permanent residency was: an expiry date (at question 15 )
Tick ONE only All Australian arrival stamps
Separate application forms for each financial year
Approved Date / / Go to 21 (if applicable)
Withdrawn Date / / Go to 21
Privacy notice
Refused Date / / Go to 19
26 Your personal information is protected by law, including the
19 If your application was refused by DIBP, have you lodged an Privacy Act 1988, and is collected by the Australian Government
appeal against that decision? Department of Human Services for the assessment and
No administration of payments and services. This information is
required to process your application or claim.
Yes
Your information may be used by the department or given to
20 Have you lodged an application for permanent residency with other parties for the purposes of research, investigation or
DIBP under parent category (Aged parent or Contributory where you have agreed or it is required or authorised by law.
parent)?
You can get more information about the way in which the
No Department of Human Services will manage your personal
Yes Date application lodged information, including our privacy policy at
humanservices.gov.au/privacy or by requesting a copy from
/ /
www.

the department.

Claiming period Declaration

21 You must complete a separate application for each 27 I declare that:

financial year you are applying for. the information I have provided in this form is complete and
We are unable to certify any period after the date this correct.
application is signed. for the period(s) specified in questions 21 and 22, I was a
All periods must be in the same financial year. resident of Australia for taxation purposes, and at the same
time I was not eligible for Medicare benefits, nor Medicare
Which financial year are you applying for? benefits under a Reciprocal Health Care Agreement.
1 July 20 ___ ___ I understand that:
to 30 June 20 ___ ___ giving false or misleading information is a serious offence.
22 Which period during the financial year were you not eligible for information regarding this application is exchanged
Medicare benefits? between the Australian Government Department of Human
Whole financial year (as stated in question 21) Services and the Australian Taxation Office.
or Applicants signature
Date
From / / to / /
-  30 / 06 / 2017
23 Are you leaving Australia permanently before the end of the
current financial year?
No
Yes Expected departure date / /

Visa verification authorisation

24 Do you give permission for the Australian Government
Department of Human Services to contact the Department of
Immigration and Border Protection to verify your current visa
entitlement for the purpose of determining your eligibility for
Medicare?
No Yes
MS015.1410 (formerly 3169) 3 of 3